The OTS/Custom-Fit Difference

After a relative lull in Medicare-related information for several weeks, the DME MACs have released a flurry of relevant data over the last 48 hours. We will have a series of posts over the next few days to catch our readers up on what they need to know, but let's start with a topic that continues to confuse people: how do you correctly bill OTS v. custom-fit orthoses?

​The DME MACs have released a new joint publication that revises a previously-published March article on the OTS/custom-fit distinction. Here's what you need to know:

The prescribing physician's order must specifically identify the need for either a prefabricated or custom-fabricated device. (Remember - prefabricated includes ​​both OTS and custom-fit items.)

OTS orthoses require only minimal self-adjustment at the time of fitting and do not require the services of a certified o​rthotist or other individual with specialized training.

Custom-fit orthoses ​require (a) substantial modification for fitting at the time of delivery (b) by a certified orthotist or an individual with equivalent specialized training ("such as a physician, treating practitioner, an occupational therapist or physical therapist").

If you deliver an item described by a custom-fit code that has no corresponding OTS code and you did not (a) substantially modify it at the time of delivery or (b) have a certified orthotist or other individual with specialized training modify it, you should bill the item with the applicable unlisted procedure code and indicate in the narrative field that you furnished the item off-the-shelf.

What does this mean for you?

There are three key takeaways we want to emphasize.

First, before you deliver an orthosis to your patient, make sure that the physician's prescription specifically lists the type of device you will be fitting: either prefabricated (which includes both OTS and custom-fit) or custom-fabricated. If the prescription does not include this information, you face the very real possibility of having your claim denied. The risk here is highest if you deliver a custom-fabricated orthosis when the prescription does not specify it. If you do not have a formal step in your internal claim process where you perform this pre-delivery check, add it immediately.

Second, the distinction between OTS and custom-fit still centers on what gets done to the device (substantial modification?) at the time of delivery and who does it (certified orthotist/individual with equivalent specialized training?). A key question with respect to the "who" requirement is which professionals fit within the definition of a "treating practitioner"?

At least one DME MAC - Noridian, Region D - has stated that this does ​not include certified orthotic fitters. Noridian has also implicitly rejected the concept of a certified orthotic fitter performing substantial modifications under the direction of an orthotist or other individual with equivalent specialized training, saying that "[t]he 'expert' must be the one performing the 'substantial modifications' in order to bill for a custom-fitted code." (Click here for the Noridian Q&A addressing this issue.)

Finally, if you find yourself in a situation where you have a brace for which only a custom-fit code exists and you either (1) do not substantially modify the orthosis or (2) do not have an orthotist or other individual with specialized training make the modifications, the MACs are saying you should use the LX999 code that applies to that item. You would indicate that the item is OTS in the narrrative description for the unlisted procedure code.

We want to point out that this last scenario has potentially far-reaching implications. Medicare created several "custom-fit only" codes based upon the supposition that certain types of braces inherently require substantial modification by certified orthotists or people with equivalent training. In other words, certain types of braces could only be custom-fit because of their complexity and the skill required to safely fit them on patients - by definition, they couldn't ever be OTS.

But now with this guidance, the MACs are creating a mechanism for devices that previously were custom-fit only to somehow morph into OTS items. We would expect the MACs to closely monitor the number of LX999 claims for "OTS" orthoses and perhaps use the resulting data as a justification for pushing more complex prefabricated braces (i.e., the historical custom-fit only items) into new, not-yet-created OTS codes. This would have the effect of increasing the percentage of orthoses ultimately included in future rounds of competitive bidding, along with the associated fee schedule cuts that would result.

We will keep you posted regarding additional information on the OTS/custom-fit distinction as it becomes available.